An Insurance Horror Story

To my fellow colleagues I share my story hoping that you will not fall prey to misinformation, deception, and error.

I was licensed as a chiropractor in 1979, and promptly purchased disability income insurance protection as any responsible, self-employed professional would do. The past 14 years I have maintained coverage with a variety of companies. In May of 1991, I purchased two policies from a major insurance company, one policy for disability income protection, the other for mortgage protection. I had a disability income policy with a high quality insurance company costing $3,200 per year. The other underwriter's policy cost $1,595 per year. The company agent assured me the policy covered me for practicing chiropractic. He was adamant that, "if I couldn't treat patients, I was covered."

In July of 1993, while at the ACA convention in Maui, Hawaii, I suffered a fracture to my left femoral neck on the hotel water slide, which then resulted in avascular necrosis of my left hip. My diagnosis was confirmed by two MRIs and a nuclear bone scan. On September 15, 1993, I contacted my insurance agent, the man who had sold me the policy two and a half years earlier. I explained my injury to him. I did not wish to jeopardize my benefits. He assured me that I was insured to practice chiropractic, and "if I couldn't treat patients, I was covered." I called him daily over the next few days to request this opinion in writing. He did not provide this despite my repeated requests. My practice included the treating of patients and evaluating cases for second opinion in disability related issues. My agent clearly stated it was okay to do "legal work," evaluations, teach, lecture, court testimony, and consult with patients. He assured me that I would not jeopardize my benefits as long as I did not treat patients. I canceled all treating patients and referred them to colleagues. I dramatically reduced my work schedule due to unrelenting and agonizing pain. I was placed on disability by a chiropractic colleague until I could obtain medical supervision with an orthopedic surgeon. After my elimination period of 60 days, the main office insurance representative contacted me and shared quite a different opinion from that of my authorized agent who had sold me the policy. She said that I was not totally disabled but only partially disabled, and therefore I was not eligible for benefits.

I have not been able to walk or stand without crutches since September 15, 1993. I suffer constant pain in my left hip that varies in intensity with certain factors. I cannot perform those primary duties of a doctor of chiropractic. I was told my circumstances were "unique" because of my specialty education and training.

Indeed my education had not stopped with chiropractic college. I had completed my bachelors degree as well as attended graduate school. I completed chiropractic postgraduate studies in orthopedics, occupational health, sports injuries, and numerous programs in disability evaluation. At the end of 1993, I completed a postgraduate program in occupational safety and health management at the University of California. I always believed that more education and training would not hurt me. It appears that if a doctor of chiropractic adds to his/her basic chiropractic education, benefits may be jeopardized or denied under such ill-defined policies. If insurance companies can interpret your ability to make a living based on all of your education, training, and specialization, they can circumvent their obligation to provide basic disability benefits which insure you to practice chiropractic.

I have heard a different song in the sales office of a particular insurance company, possibly other insurers may play this same tune. It appears the sales agents may say whatever they want, and the company may disagree and withhold payment of benefits.

I have been on total disability at the direction of my orthopedic surgeon since December 1993. I underwent surgical core decompression of the left hip with bone grafts packed into the necrotic femoral head. I live with the constant use of a TENS for pain control. I still cannot walk or stand without crutches. The expected clinical course is two to three years, if all goes well. If the femoral head collapses, I'll be looking at a hip replacement.

Despite the magnitude of my condition, the insurance company withheld my benefits for four months. During that time, I had no means of income. I borrowed a large sum of money to live on and pay my bills. Only after I hired an attorney, at a significant cost, and wrote numerous letters, did I get my benefits.

My fellow colleagues, I recommend you question your company's main office to obtain the opinion of the person who matters, the claims agent. Get that opinion in writing. Do not believe the sales agent without a thorough look at all the opinions of authority.

I pose some serious questions to you. Please take a moment to answer these and think of others. Who does your insurance company really answer to? Are you capable of providing health services other than treating patients? Have you taken any postgraduate training? Do you have any certificated specialties? Do you do any second opinion exams, AMEs, IMEs, or QMEs?

I am suggesting you tread softly and find out exactly what you're insured to perform, and what hoops must be jumped in order to obtain those very important and virtually life sustaining benefits in the unfortunate event you cannot practice chiropractic. My advice is that you get the facts, and protect yourself, your family, and your practice.

David P. Gilkey, DC, DABCO, DACBOH
Broomfield, Colorado